Cập nhật về phòng ngừa đột quỵ cho bệnh nhân rung nhĩ PGS trương quang bình

CẬP NHẬT VỀ PHÒNG NGỪA ĐỘT Q CHO BỆNH NHÂN RUNG NHĨ PGS TS TRƯƠNG QUANG BÌNH AF accounts for 1/3 of all patient discharges with arrhythmia as the principal diagnosis Data source: Baily D J Am Coll Cardiol1992;19(3):41A The prevalence of AF in the Asian population is predicted to increase dramatically In China, it is estimated that 5.2 million men and 3.1 million women aged >60 years will have AF by 2050 Men 2050 5000 4000 3000 2025 2000 2050 2025 2000 1000 2000 60–64 60–69 60–74 60–79 Age (years) Tse HF et al Heart Rhythm 2013;10:1082–8 Women 6000 60–85 Adults with AF, 1000s Adults with AF, 1000s 6000 China USA 5000 4000 2050 3000 2000 2025 2050 2025 2000 2000 1000 60–64 60–69 60–74 60–79 Age (years) 60–85 Atrial Fibrillation Symptomatic AF: Only “the tip of the Iceberg” Symptomatic AF Silent AF Rung nhĩ làm tăng tỷ lệ tử vong & nguy ĐQ tái phát Tử Vong Cumulative probability of recurrence (%) • 3,530 patients with first-ever ischaemic stroke • AF was confirmed by ECG in 869 patients (25%) • Mean age at stroke was 78.8 years Đột quỵ tái phát p = 0.0398 AF No AF Months since event Marini C, et al Stroke 2005;36;1115-9 CÁC TIẾP CẬN ĐIỀU TRỊ RUNG NHĨ  Phòng ngừa đột q  Thuốc chống loạn nhòp đưa nhòp xoang  Các biện pháp điều trò triệt để đưa nhòp xoang  – Phẫu thuật (Maze) – Cắt đốt ống thông Kiểm soát đáp ứng thất – Bằng thuốc – Thay đổi / cắt đốt nút nhó thất ống thông Left Atrial Appendage Left atrium LAA: source of 90% of AF-related thrombia a Blackshear JL, et al Ann Thorac Surg 1996;61:755-759.[5] Patrick J Lynch, medical illustrator; C Carl Jaffe, MD, cardiologist http://creativecommons.org/licenses/by/2.5/ Consequences of AF • Formation of blood clots on the left atrium that can dislodge, leading to stroke and systemic embolism Dabigatran 150 mg is the ONLY NOAC with superior reduction of both ischemic and hemorrhagic stroke vs warfarin and no compromise in safety Dabigatran 150 mg Rivaroxaban 20 mg Apixaban mg Stroke/SE Superior Non-inferior Superior Ischaemic stroke Superior Non-inferior Non-inferior Haemorrhagic stroke Superior Superior Superior Major bleeding Superior Non-inferior Superior Compare to warfarin (Asian population) Not head-to-head comparison – no clinical conclusions can be drawn – adapted from references 1–6 Connolly SJ et al N Engl J Med 2009;361:1139–51; Connolly SJ et al N Engl J Med 2010;363:1875–6; Hori M et al Stroke 2013;44:1891–6; Patel MR et al N Engl J Med 2011;365:883–91; Granger C et al N Engl J Med 2011;365:981–92; Giugliano RP et al N Engl J Med 2013; doi:10.1056/NEJMoa1310907 24 Sept 2012 Evolution of stroke risk in AF Placebo 4.3% ASA Annual stroke rate 3.3% ASA + clopidogrel 2.4% Adjusted-dose warfarin 1.7% Dabigatran 110 mg Dabigatran 150 mg 1.54% 1.11% Antithrombotic therapy ASA = acetylsalicylic acid; Ezekowitz M et al N Engl J Med 1992;327:1406–12; Connolly SJ et al N Engl J Med 2009;360:2066–79; Connolly SJ et al Lancet 2006:307:1903–12; Connolly SJ et al N Engl J Med 2010;363:1875–6 Risk of stroke according to CHA2DS2-VASc CHA2DS2-VASc criteria Score Congestive heart failure/ left ventricular dysfunction Hypertension Age 75 years Diabetes mellitus Stroke/transient ischaemic attack/TE Vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) Age 65–74 years Sex category (i.e female gender) Total score N Adjusted stroke rate (%/year)* 0.0 422 1.3 1230 2.2 1730 3.2 1718 4.0 1159 6.7 679 9.8 294 9.6 82 6.7 14 15.2 *Adjusted for warfarin use Theoretical rates without therapy; assuming that warfarin provides a 64% reduction in stroke risk, based on Hart RG et al 2007 TE = thromboembolism Lip G et al Chest 2010;137:263–72; Lip G et al Stroke 2010;41:2731–8; ESC guidelines: Camm J et al Eur Heart J 2010;31:2369–429; Hart RG et al Ann Intern Med 2007;146:857–67 Dec 2011 Latest ESC guidelines recommend NOACs over VKAs Atrial fibrillation = CHA2DS2-VASc Yes Valvular AF* = CHA2DS2-VASc ≥2 No (i.e non-valvular) Yes = CHA2DS2-VASc 160 mmHg) Abnormal renal or liver function (1 point each) Score 1 or HAS-BLED total score N Number Bleeds per 100 of bleeds patient-years* 798 1.13 1286 13 1.02 744 14 1.88 Stroke 187 3.74 Bleeding 46 8.70 12.5 0.0 – – – – – – (history or predisposition) Labile INRs Elderly (e.g age >65 years) Drugs† or alcohol (1 point each) or *P value for trend = 0.007; †Antiplatelets and non-steroidal anti-inflammatories; INR = international normalized ratio; SBP = systolic blood pressure Pisters R et al Chest 2010;138:1093–100; ESC guidelines: Camm J et al Eur Heart J 2010;31:2369–429 Dec 2011 NICE 2014: Stroke prevention of people with nonvalvular AF Assess stroke risk stratification using CHA2DS2-VASc Assess bleeding risk stratification using HAS-BLED People who choose not to have treatment Discuss risks and benefits of anticoagulation Identify low risk patients i.e CHA2DS2-VASc = (men) or (women) CHA2DS2-VASc = (in men) Consider oral anticoagulant CHA2DS2-VASc ≥ (in women) Offer oral anticoagulant Low risk No anti-thrombotic therapy Anticoagulation contraindicated Discuss the options for anticoagulation with the person and base the choice on their clinical features and preferences Vitamin K antagonist NOAC (Non-VKA oral anticoagulant) Non-VKA contraindicated or not tolerated Assess anticoagulation control Poor control NOAC (Non-VKA oral anticoagulant) Left atrial appendage occlusion Annual review for all patients National Clinical Guideline Centre Atrial fibrillation: the management of atrial fibrillation June 2014 Available at: www.nice.org.uk/xxxxx (accessed June 2014) UK/CVS-141039 | June 2014 Left Atrial Appendage Definitive indication for LAA Closure Patients with contraindications for long-term anticoagulation Parekh A et al Circulation 2006;114:e513-e514 Amplatzer Cardiac Plug (ACP) - Recurrent ischemic stroke despite well control therapeutic OAC - Previous ICH - Recurrent GI bleeding - Co-morbidities (uncontrol hypertension, cerebral microbleeds,…) - Coagulopathies (low platelet counts …) - Intolerance to NOACs Lewalter T, Europace (2013) 15, 652–656 KẾT LUẬN • Rung nhĩ (non valvular): thường gặp • Nguy gây đột quị rung nhĩ cao hậu nghiêm trọng • Phòng ngừa đột quị cho rung nhĩ: khó khăn • Biện pháp phòng ngừa chủ yếu: OAC (new) • Loại bỏ tiểu nhĩ trái dụng cụ: có định NC nhiều Thank you for your attention !